THERAPEUTIC FORUM

Differentiating Preseptal from Orbital Cellulitis

Christopher J. Quinn, O.D.

Cellulitis can often pose a mystery on many levels. We have to first determine that the patient’s complaints add up to cellulitis, then determine the etiology, which drives the drug of choice. Finally, we must decide on a treatment strategy. This case provides an example.
A 32-year-old white female presented with a two-day history of increased pain and swelling of her right eye and eyelid. She denied a previous history of trauma, previous episodes of pain and/or swelling, reduced visual acuity or diplopia. The patient was afebrile, and her medical, prior ocular and social histories are all noncontributory. She reported no known drug allergies.

The exam revealed best-corrected acuity of 20/20 O.U. External examination revealed swelling of the right upper eyelid. The eyelid was erythematous and painful, especially in the center. All other ocular findings were unremarkable.

Diagnosis
This patient had an internal hordeolum and associated preseptal cellulitis. It often results from traumatic inoculation, or an extension of a localized infection of the skin or eyelids—in this case, an internal hordeolum.

The infection limits itself to the tissues anterior to the orbital septum—a layer of fascia that extends from the inferior orbital rim to the levator aponeurosis in the superior lid and to the

tarsal plate of the inferior lid, creating a physical barrier to the orbit.

It’s important to differentiate preseptal from the more serious orbital cellulitis, not only because it will determine your treatment strategy, but also the latter is a potentially life-threatening condition.

The More Serious Cellulitis
Most cases of orbital cellulitis result from the spread of infection from either the ethmoid sinuses or direct trauma. Rarely do infections spread into the orbit, but once they do, the associated swelling can cause compression of the optic nerve. Infection can also extend into the cavernous sinus, thus leading to thrombosis, meningitis and encephalitis. These intracranial complications are the most feared.

Several key clinical features help differentiate orbital from preseptal cellulitis. It’s critical to test for all of these because an abnormality in any of these suggests an infection of the orbit and represents a true ocular emergency:

• Patients with orbital cellulitis will develop proptosis as the swelling increases in the orbit; the pressure causes forward displacement of the globe. A proptosis of 2mm or greater is abnormal.
• Patients will develop restriction of extraocular motility, diplopia and disturbed extraocular motility.
• Patients will frequently complain of pain on eye movement.
• Finally, patients can develop optic nerve dysfunction, which can manifest as reduced acuity, an afferent pupillary defect, or a reduction in color vision.

Management Approaches
Patients with preseptal cellulitis can be managed more conservatively. Initiate frequent warm soaks to increase circulation and enable abscess drainage. Topical antibiotics do not penetrate into the lids’ soft tissues, so they’re ineffective in treating this condition. Instead, start the patient on oral antibiotics, such as 250mg Keflex (cephalexin) QID, 500mg of dicloxacillin BID, or 500mg of ciprofloxacin BID to control the infection. Carefully monitor for signs of a progressive infection. Most will respond to treatment within two to three days, but should continue the oral antibiotic for at least 10 days.

Patients with orbital cellulitis, on the other hand, demand a more aggressive approach. They should have immediate orbital CT-scans to confirm the diagnosis. These patients will most likely need to be hospitalized and have immediate treatment with intravenous antibiotic. Orbital decompression may be indicated if optic nerve function is severely compromised.

I successfully treated this patient with Keflex 250mg QID and warm compresses. She responded well to treatment and had a gradual reduction of pain and swelling. Seven days later, her condition had resolved.

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